AGING, INDEPENDENT LIVING AND TECHNOLOGY - A White Paper by the Foundation for Internet and Society
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AGING, INDEPENDENT
LIVING AND TECHNOLOGY
A White Paper by the Foundation
for Internet and Society
FOUNDATION FOR INTERNET AND SOCIETYDIGITAL URBAN CENTER FOR AGING & HEALTH
AGING, INDEPENDENT
LIVING AND TECHNOLOGY
A White Paper by the Foundation
for Internet and Society
AUTHORS
Paul Jackson, Thomas Schildhauer, Annika Ulich, Jörg Pohle, Stephan A. Jansen
Berlin, June 2021AGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
EXECUTIVE SUMMARY
There is a significant demographic trend of Within the ecosystems of the elderly, there are
aging, particularly in the wealthier Western several significant stakeholders to be consid-
nations. This trend is putting governments and ered, all of whom have an interest in digital solu-
caregivers under increased pressure to pro- tions to support aging in place; these include
vide affordable support for a form of aging in the senior citizens themselves, their concerned
place that enables the elderly to lead dignified, relatives or the governments responsible for
meaningful and engaged lives for as long as providing funding and structures. The methods
possible. Particularly in this time of COVID-19, for designing, testing and researching techno-
when access, distancing, infection control and logical products and services are hence moving
healthcare have become primary concerns, into sharp focus due to the importance and
digital solutions may offer this vulnerable group complexity of these challenges and the diversity
ways to enhance their safety, autonomy and of objectives among stakeholder constituencies.
resilience. A flood of technological products and
services have appeared to cater to this emerging While there is a growing body of research exam-
market and meet government demands to keep ining the effectiveness and success of adoption 3
the elderly in their own homes, which is the and use of technological products and the
preferred location for many aging individuals. associated services, the absence of participatory
design is a particular concern. Some research is
THE SCOPE OF HEALTHY AGING AT experimental but most has involved surveys and
HOME EXTENDS BEYOND THE HOME interviews or product evaluations; on the whole,
TO LOCAL STRUCTURES AND FACILITIES it has been highly product focused.
These products include assistive technologies THE ABSENCE OF PARTICIPATORY
as well as technologies to monitor safety and DESIGN IS A PARTICULAR CONCERN
health and provide company and social inte-
gration. The technologies can be individual and There has been little observation and assess-
wearable but also embedded within the overall ment of in situ applications of these technolo-
context of a smart home and a neighbourhood gies, and we thus have little idea of how people
designed to enhance elderly well-being, as actually use them and how much they contribute
the scope of healthy aging at home extends to the goal of independent living. The ways in
beyond the immediate confines of the home to which technologies interact with each other and
local structures and facilities. In general, these with the complex realities and trajectories of
products have not considered the complexities elderly life remain opaque.
of aging and the needs and expectations of the
elderly, who are typically not included in design This has led the Digital Urban Center for Aging
processes, nor have they been researched in and Health (DUCAH) – an initiative of the
depth to assess their acceptance or efficacy. The Foundation for Internet and Society and the
trend towards aging in place is also creating Alexander von Humboldt Institute for Internet
challenges for those engaged in the practice of and Society in partnership with the Einstein
caring: doctors, nurses, carers, workers in allied Center for Digital Future (ECDF) and several
health areas and relatives. practice-focused organisations – to developAGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
DUCAH ENABLES COLLABORATION Labs). The development of new solutions within
BETWEEN STAKEHOLDERS TO this ecosystem is based on a user-centric design
IMPLEMENT AND TEST NEW approach. Here, both research processes and
PROCESSES AND TECHNOLOGIES innovation processes are integrated into real-life
living and working settings. In this natural envi-
the Learning Lab as its research platform. The ronment, the elderly, their relatives, carers and
Learning Lab can be understood as an open care organisations, governments and regulators
innovation ecosystem that operates at the inter- and other stakeholders in the ecosystem can
face between urbanisation, digitalisation and participate and collaborate to implement and
health; it is intended to be similar in concept test new processes and technologies for bene-
to the Living Labs (European Network of Living fits, enhancement, acceptability, and usability.
4AGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER CONTENTS Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Purpose and facts on current aging debates ADAPTIVE AGING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 5 Relevant domains and stakeholders TECHNOLOGY IN AGING AND HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Technology opportunities, design and context CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Gaps in knowledge and proposal for research approaches References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 About . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
INTRODUCTION Purpose and facts on current aging debates
AGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
This white paper discusses the rapid increase in The purpose of this white paper is to provide
aged cohorts in most countries of the world and information on the range of solutions and the
the challenges and opportunities it presents for current state of research into aging in place.
those involved – governments, service provid- Although our focus is on technologies that
ers, technology companies, carers and relatives, support the elderly in remaining in the home
and the elderly themselves. In it, we describe
the demographic and social changes driving WE MUST CONSIDER HOW AGED
the need for action and policy efforts on digital CARE HOMES CAN BE SHAPED AND
health in Germany and Europe. Innovative solu- EQUIPPED TO DELIVER STATE-OF-THE-
tions that ensure that older people can enjoy a ART SERVICES THAT SUPPORT HEALTH,
dignified, meaningful and self-determined life WELL-BEING AND A RICH SOCIAL LIFE
are needed.
and enjoying an active, healthy and socially con-
These solutions will be found in domains such nected life, we must also consider how aged care
as healthcare and nursing, monitoring and homes can be shaped and equipped to deliver
assistive technologies, architecture and town state-of-the-art services that support health,
planning, government policy and regulation, well-being and a rich social life. We review the 7
psychology and caregiving. But the lives and research into these technologies and consider
concerns of the elderly themselves must be the their interaction with the needs and expectations
primary consideration. Great care must be taken of the elderly and identify issues in the research
to ensure that they do not become passive recip- and gaps in knowledge.
ients of supply-side, interventionist policies and
disempowering design processes.
THE CURRENT AND FUTURE SITUATION
Any definition of the elderly will necessarily be Forecasts predict that the number of older peo-
imprecise: older people or pensioners cannot be ple who will need care will increase considerably
located in an exact age span, as individuals vary in most Western societies over the next 30 to 80
widely in their biological, psychological and cul- years. By 2050, the number of older people in
turally defined aging characteristics. Generally, Germany will have doubled to about 4.7 million.
the terms refer to a period when individuals Within the EU-27, the share of the elderly “…
reach the end of their working lives and when is projected to increase from 20.3% (or 90.5
age-related conditions may begin to appear. In million elderly persons) at the start of 2019 to
developed countries, this is generally seen to 31.3% (or 130.2 million elderly persons) by 2100
be between 60 and 65 years of age, though in (eurostat Statistics Explained, 2020b). As such,
Africa, this is considered to be around 55 (World the share of the elderly is projected to rise by
Health Organization, n.d.). But aging is also a 11 percentage points, reflecting an additional
process and not just a stage. It might even begin 39.7 million elderly persons by 2100” (eurostat
at 50, and indeed the preparations for aging or Statistics Explained, 2020b). By 2034 in the
the need for assistive technology or appropriate United States there will be 77 million people
accommodation can begin earlier and be shared aged 65 years and older and by 2030, 1 in every
with other age cohorts. 5 residents will be of retirement age (UnitedAGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
States Census Bureau, 2018). The number of up from 15.6% in 2020 (Park et al., 2019). At
elderly people living alone in Korea tripled from the same time, the age dependency ratio, that is
2000 to 2014, from 540,000 to 1.44 million. By the number of working people who support one
2026, this will reach 20.8% of the population, aged person will have risen:
– In the United States, while in 2020 there were about 3.5 working age adults for every retirement-age
person, by 2060 that ratio will be 2.5.
– The EU-27’s old-age dependency ratio will almost double from 31.4% (or just over 3 persons of work-
ing age for every person aged 65 or over) in 2019 to 57.1% by 2100, as can be seen in the figure below.
– In Korea, in 2004 there were 8.2 working age people for each senior citizen, by 2030 this will be 2.8.
“This will, in turn, lead to an increased burden on those of working age to provide the
social expenditure required by the aging population for a range of related services”
(eurostat Statistics Explained, 2020a).
In Germany in 2017, there were 3.4 million peo- of conditions associated with loss of cognitive
ple needing care. By 2050, this figure will grow function, will affect a growing number of people 8
to 4.7 million, an annual growth of 1.6%. It is in future, climbing from 50 million affected peo-
estimated that about 1.7 million support staff ple globally now, to 82 million by 2030 and 150
and carers will be needed. According to some million by 2050.
estimates, dementia, a general term for a range
“Before the pandemic, about a quarter of hospital beds in British hospitals were occu-
pied by people with dementia. There was nowhere else for them to go” (The Economist,
2020).
The economic bottom line is relentless and Indeed, the potential to apply digital technolo-
unequivocal: there will be greatly increased gies to optimise the business processes of care
demand, requiring significantly more resources organisations, automate both care and support
in a highly human-centred industry. This activities, reduce manual work and reduce travel
demand will be funded by fewer and fewer tax- and movement is particularly high. The quality of
payers and there will be an expected shortfall in encounters in prevention and care can improve,
care professionals. It is essential that produc- and more individualised care and medical treat-
tivity is increased: “more of the same will not ment can be provided (Roland Berger GmbH,
be enough” (World Health Organization, 2015). 2017).100 %
80 + years
80 %
65 – 79 years
60 %
40 % 15 – 64 years
20 %
0 – 14 years
0%
2019 2030 2040 2050 2060 2070 2080 2090 2100
Population structure by major age groups, EU-27, 2019-2100(own presentation, based on eurostat Statistics Explained, 2020a)
100 %
80 %
old-age
60 % dependency ratio
55.7 % 56.7 % 57.1 %
52.0 % 54.0 % 54.0 %
40 % 46.8 %
39.1 %
31.4 %
20 %
0%
2019 2030 2040 2050 2060 2070 2080 2090 2100
Projected old-age dependency ratio, EU-27, 2019-2100 (own presentation, based on eurostat Data Browser, 2021)
PROJECTED AGE STRCTUREAGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
AGING IN PLACE
The U.S. Center for Disease Control and Prevention (CDC) defines aging in place as:
“The ability to live in one’s own home and community safely, independently, and com-
fortably, regardless of age, income, or ability level.” (Centers for Disease Control and
Prevention, n.d.)
The overwhelming preference of aged people the elderly population would be prepared to live
and those needing care is to remain in their own in shared accommodation or with their family.
home, a familiar social and physical environ- Less than 40% would want to live in a nursing
ment. This often concerns the family home but home.
also applies to homes managed within a larger
complex. Aging at home is also the most eco- Perhaps almost as important as the home is the
nomically sustainable configuration of capital, community in which it is embedded: familiar
accommodation and services. The maintenance streets, shopping and exercise facilities, access
of good health and independence for as long as to transport, multi-generational networks and 10
possible is the primary goal. Other forms such relationships, and the sense of belonging and
as co-housing and retirement complexes have mobility these generate. As neighbourhoods
evolve or are developed, consideration of the
MAINTENANCE OF GOOD HEALTH AND needs of the growing cohort(s) of the aged will
INDEPENDENCE AT HOME FOR AS LONG become more salient but these developments
AS POSSIBLE IS THE PRIMARY GOAL will require long-term, strategic attention and
investment, in particular as regions undergo
some specific advantages, such as greater social structural and economic changes that may limit
support, lower isolation and an increased sense the supply of services (Bundesministerium für
of safety (Rusinovic et al., 2019). About half of Familie, Senioren, Frauen und Jugend, 2020).ADAPTIVE AGING Relevant domains and stakeholders
AGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
When designing technologies for adaptive aging, work and leisure (Van Bronswijk et al., 2002). A
it is important to consider the key domains of report to the National Research Council of the
elderly function and activity and not only focus National Academies in the United States divides
on the capacity of technology to “fix issues” or these into communication, employment, health,
“address productivity bottlenecks”. There are learning living environment and transportation
a number of taxonomies for these functional (Pew & Van Hemel, 2004). The DUCAH initiative
areas, covering issues such as health and focuses on three intricately connected domains
self-esteem, mobility and transport, housing of aging.
and living, communication and governance, and
HEALTH
The elderly are the largest group of consumers constant care. Thus, it is necessary to develop
of healthcare and appliances and health is the technologies that can detect abnormal physical
most prominent and promising domain of conditions at an early stage. Such information 12
age-related technology. The safety benefits of can then be communicated to medical experts
condition monitoring, fall prevention, med- for appropriate analysis and decision making
ication management and compliance, and (Park et al., 2019).
telehealth are considerable (avoidance of acute
incidents, suffering and trauma, faster response But with health and condition monitoring that is
to incidents), as are the potential cost savings potentially so comprehensive, a significant chal-
(reduction in hospital emergencies and stays, lenge is to ensure that the elderly are shielded
fewer medical staff required, and so on) (Kim et from the anxiety and stress of information over-
al., 2017). load and interventions. There are large quan-
tities of data that must be refined for patients
HEALTH IS THE MOST PROMINENT and caregivers, and there are ethical and liability
AND PROMISING DOMAIN OF issues emerging from possible malfunctions
AGE-RELATED TECHNOLOGY (Bächle & Wernick, 2019). Cost is also an issue.
Furthermore, geriatric diseases are typically With ever-smaller families to care for them and
accompanied by other complex diseases, overstretched nursing homes, the difficulties of
which have ambiguous symptoms that change caring for sufferers of dementia is acute. As the
unexpectedly and require comprehensive and Economist says:
“The question most often asked is how to pay for it… And an even more fundamental
question than who pays for care is: who will do it? Undertaken with humanity and dignity,
it is extremely labour-intensive. Technology can help lighten the load – using remote
monitoring ... and perhaps in future robots to perform some basic tasks. But looking
after people with dementia requires people” (2020, p. 9).
Mental health care is an area that is revealing Relying as it does upon conversation, it is one
the promise of communications technologies. of the few areas of standard telehealth alreadyAGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
in widespread use by consulting clinicians. For depression in later life. Such trials have found
instance, positive results have been found in improvements in depressive symptoms and
clinical trials of the online life review method, engaged living (Westerhof et al., 2019).
an effective, evidence-based treatment for
LIVING ENVIRONMENTS
An appropriately furnished and well-equipped equipped with devices that can provide comfort
living environment is the basic prerequisite for and mitigate disabilities, support daily activities,
independent aging. The most basic design fea- and allow caregivers to provide remote care and
tures require attention – stairs and rugs should intervention. Technology in the home can com-
be avoided and physical supports installed, but pensate for motor and cognitive changes. There
aesthetic, mood enhancing design consider- are several challenges and barriers to adoption
ations, such as having a bright room and a nice here, such as high cost, complexity and ease of
view, are also relevant. Smart homes are the use, systems reliability and privacy (Pernice & 13
most salient technology in living environments Pohle, 2018).
for the elderly: fully networked, they can be
MOBILITY AND THE NEIGHBOURHOOD
Movement is a cornerstone of healthy living, this ecosystem is the enabling of movement” as
and this equally applies to aging. In its simplest well as the integration of green areas and spaces
form, mobility means that housing itself must for physical activity and social interaction.
be safely navigable, but the individual’s wider
surroundings should facilitate mobility, safety THE SURROUNDINGS SHOULD
and access to services, companionship and FACILITATE MOBILITY, SAFETY
leisure. The feature of the neighbourhood that AND ACCESS TO SERVICES,
are particularly challenging for older people COMPANIONSHIP, AND LEISURE
need to be addressed – for example, authorities
should provide dementia-friendly pathways, This form of neighbourhood development
street layouts and designs and promote social requires long-term strategic thinking and inno-
programmes that educate others on how to deal vation as it involves district redesign and the
with those suffering from dementia. inclusion of inter-sectoral stakeholders with
different innovation logics and aspirations. The
Chrysokou et al. call for the development of an intensification of work on smart cities, transpor-
integrated architecture for “enabling spaces”, in tation and digital health serves to illustrate the
which health, social and environmental factors need for forums in which exchange and mutual
can be co-designed to create spaces optimally understanding of these objectives and logics can
oriented towards healthy and active aging be facilitated and which then support sustained
(2018). As they state, “a crucial component of collaboration and co-design.AGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
STAKEHOLDERS
The primary stakeholder in the context of this Other important adaptive aging stakeholders
discussion is of course the aging person. People are non-profit organisations and associations
who need care, but also their relatives and representing the various providers in health,
caregivers, are the focus of interest, and their technology and mobility as well as patients’
needs and specific problems form the basis and older people’s organisations and self-help
for research and exchange with the other stake- groups. They have a deep understanding of the
holder groups. groups they represent and can in turn make this
available to other stakeholders so that inno-
But the goal of independent, healthy living for vation is closely aligned with the needs of the
older people requires the involvement of further target groups. All of these actors are multipliers
stakeholders, each with their own particular and provide a network for testing solutions in
perspectives and objectives, and technological suitable organisations and for bringing digital
solutions must also deliver benefits for them. solutions to the wider public.
Research institutes and the scientific commu-
nity have to focus on all participants in this eco- Depending upon country-specific policies and 14
system. They will need to be involved to some funding, the (commercial) care sector has an
degree in researching and designing products, interest in the efficiency and productivity of the
services, processes and environments for aging. care process. This sector’s need for technology
affects all stages of the business cycle: acquiring
Relatives and children have a substantial influ- customers, securing funding, complying with
ence on older people’s decisions to acquire regulation, establishing people at home with
technologies. In general, this group focuses on appropriate technologies and appliances, pro-
older people’s care, comfort, and safety. They viding carers and cleaners, coordinating these
may pay for commercial operators to monitor resources optimally, conducting medical moni-
and provide care or take on a more substantive toring and intervention, and invoicing. In many
role themselves, such as the role of a primary cases, they look to provide excellent care prod-
carer or initial responder in a crisis. Alternatively, ucts and services that differentiate them from
some members of this group may take little other providers. Further, they require a workforce
interest and simply wish to “outsource” the care. of clinicians, allied health professionals and care
staff in an environment that is labour-intensive
Governments fund much aged care, providing and often characterised by low wages and inse-
financial, and sometimes means-tested, pack- cure employment.
ages for home care depending upon levels of
infirmity. While there may be public pressure on Technology providers cover a wide spectrum of
politicians to provide equitable care, government technologies and services and have a commer-
budgeting means that cost control is a primary cial focus. Some service providers offer the basic
motivator, often prompting a move to user-pays infrastructure and platforms for transmitting
systems. This stakeholder group is interested in data and facilitating the installation of services
efficiencies and the ability to leverage the effec- by other providers, such as health monitoring,
tiveness of capital and human resources. movement and fall recognition, medicationAGING PEOPLE
Primary stakeholder in the context
RELATIVES AND CHILDREN CAREGIVERS
These have a substantial influence Providing remote care
on older people and intervention
RESEARCH INSTITUTES GOVERNMENTS
Engaged in the research and design of Substantive funders of aged care, interested in
services, processes and environments effective use of capital and human resources
NON PROFIT ORGANISATIONS AND ASSOCIATIONS CARE SECTOR
Representing the various providers, patients’ and Interested in efficiency and productivity
older people’s organisations and self-help groups of the care process
TECHNOLOGY PROVIDERS RESIDENTIAL CONSTRUCTION
Providing the basic infrastructure and platforms Age-appropriate and inclusive
for transmitting and facilitating data living environments
HEALTH SYSTEM INSTITUTIONS FINANCE
Medical insurance funds, hospitals and allied Provider of new financing instruments, e.g. social impact
health professionals are critical participants fonds, reinvestment for affordable healthcare solutions
STAKEHOLDERS OF ADAPTIVE AGINGAGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
monitoring and so on. Some provide end-user health professionals are critical participants, as
focused devices or platforms for the elderly: they seek to manage escalating demand. For
emergency buttons, care robots, computers, or example, the growth in chronic illness, particu-
phones for the elderly. Startups are of particular larly among older people, is driving a need for
interest in this regard – they are often the source shared care models and care plans that use
of service and product innovation and new busi- digital information technologies to coordinate
ness models (Puls & Matusiewicz, 2020). referrals, diagnostics and therapies and move
treatment and appointment attendance away
Aligning the living environment with the needs from large tertiary hospitals to smaller, more
of older people is a key challenge for housing local and even “virtual” clinics. When designing
companies and the residential construction sec- such models, it is important to consider other
tor. Demographic change is widening the gap dimensions of being older – mobility, cognitive
between the available supply of housing and the capacity, access to technology and so on.
demand for accommodation that is designed
from the outset to enable older people to live As far as innovation processes in the field of
self-determined lives in the long term. The digital healthcare solutions are concerned, the
positive consequences of age-appropriate con- refinancing of healthcare services, reinvestment 16
struction and remodelling include an improved of profits in the health care sector and use of
quality of life, including for families and people social return instruments often represents the
with disabilities, and an increased residential starting points for discussions. Only through
mix. the participation of financial stakeholders can
solutions that make good services financially
Institutions within the health system including feasible be developed.
health insurance providers, hospitals and alliedTECHNOLOGY IN AGING AND HEALTH Technology opportunities, design and context
AGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
Technologies can be divided into two types, US Department of Health and Human Services
those that seek to prevent, postpone, or detect (Aykan, 2012) into aging services technologies
conditions or events, and those that seek to pro- refined these into further categories:
mote and maintain outcomes. A report by the
PREVENTION, POSTPONEMENT PROMOTION AND MAINTENANCE
AND EARLY DETECTION
– Chronic disease management
– Fall prevention and recognition – Medication management
– Cognitive impairment – Diet and nutrition
– Sensory impairment – Physical activity
– Mobility impairment – Activities of daily living
– Functional decline – Social contact and depression
– Wayfinding and mobility
18
Technology vendors have continued to develop can also be helpful in dealing with other stake-
an increasing array of healthcare products that holders in the healthcare space, such as govern-
offer great promise in the area of telehealth ment agencies and insurance companies.
because they can delay the onset of acute care
and allow the elderly to remain independent Most of these technologies involve monitoring,
for longer. Products such as wearables, smart collecting, storing and integrating data, while
fabrics, alarms, bio-medical devices and sensors others facilitate contact with other individuals,
can help individuals to manage their physical such as friends, relatives, and service providers.
health and well-being, but other products such High-speed wide-area networks, such as 5G,
as video conferencing, social robots and smart powerful local processing, big data and social
user interfaces for the elderly can also address media allow convergent innovations to be devel-
mental health issues arising from loneliness, oped in and across any of these categories to
increasing cognitive impairment and isolation. gather health information for future reference
The use of household appliances designed for through biomedical devices. They can also
the elderly can make life easier. provide highly personalised advice and infor-
mation on individual mobile devices and allow
Caregivers can be more productive and efficient ubiquitous, personalised guidance on walking,
by using this technology to constantly monitor exercising or driving through sensors and GPS.
health, safety and well-being. Digital solutionsAGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
According to medical technology experts, examples of innovation and change enabled by technology
include1:
– Artificial intelligence for the diagnosis, monitoring and prevention of medical conditions and incidents
– The use of AI and robots to substitute for human medical care
– Greater specificity in prescribing and measuring health outcomes
Increasing digitisation and better data availability will also have other consequences:
– A greater presence of big tech companies in the health market
– The development of care and health ecosystems by other players and startups
– The rise of data-driven platforms for health and elder care
– The ability to customise insurance charges, creating a portfolio of healthier clients
Given the cost and lack of public and health of the features of technological assistance. The
insurance funding for most products, the almost first shows a sequence of events for an elderly 19
universal presence of the smartphone presents man who lives alone, experiences a fall and suf-
particular opportunities to provide services such fers as a result of the subsequent trauma.
as chronic disease management, social engage-
ment and health promotion across the digital The following illustration shows the same
divide. More generally, simpler devices with less sequence of events but is a scenario in which
functionality (“frugal innovation”) may not only technology and system integration are able to
be more affordable but also preferable in the significantly reduce the trauma and cost and lead
context of aging. to better clinical and social outcomes. System
interoperability, shared platforms and the devel-
THE ALMOST UNIVERSAL PRESENCE opment of clinical information repositories such
OF THE SMARTPHONE PRESENTS as the electronic medical record (EMR) allow
PARTICULAR OPPORTUNITIES health services, care service providers and their
TO PROVIDE SERVICES staff, ambulance providers and even authorised
acquaintances to provide optimal support and
The two illustrations below portray the differ- recovery.
ence between aged living with and without some
1 See also https://www.ageinplacetech.com/ for a comprehensive, current list of technologiesFred Müller is 80, lives at home alone, walks with a cane, receives
home care and is being treated for a number of medical complaints.
Fred has a fall and lies immobile on
the floor, unable to get up.
Maria Merkrath is Fred’s carer who comes Luckily, Fred’s neighbour finds
and provides assistance twice a week. him and calls an ambulance.
John is a cleaner who comes once a week.
Both work for a private care provider.
Maria comes to care for Fred, but
finds Fred is not at home, cannot
reach him and has no-one to contact. Fred is given painkillers and gets transported to a
hospital, where he is treated for a fractured bone,
bruising and dehydration. He is disoriented and
unable to give his medical and medication history.
After being discharged from hospital, Fred is
taken home. He gets an appointment with his
primary care doctor, to take place six days
later. He feels weak and vulnerable. He calls
the care company to recommence services, Fred’s primary care doctor does not receive a
but Maria has been allocated elsewhere and a discharge summary in time. She applies for
new carer comes. The cleaner John could not increased services for Fred, but it is difficult to
access the house and the house is dirty. access. He does not know how to organise this
himself.
Fred is left stressed and anxious and unwell.
The new services he requires have not arrived ...
TRAUMAS OF AGED LIVINGFred Müller is 80, lives at home alone, walks with a cane, receives
home care and is being treated for a number of medical complaints.
Although 80, he uses social media.
Fred has a fall. His alarm is activated,
notifying the care organisation. They
view his status through video.
Maria Merkrath is his carer who comes and An ambulance is dispatched.
provides assistance twice a week. John is a His medical history, including
cleaner who comes once a week. Both work allergies and alerts, is provided
for a private care provider. as well as his disability status.
Maria comes to Fred as soon as he
arrives home with a treatment and
care plan based on hospital informa- Fred is given appropriate painkillers and gets
tion. She lets the cleaner in prior to transported to a hospital, where he is treated for a
Fred’s arrival, so the house is clean fractured bone, bruising and dehydration. He is
and welcoming. given his standard medication and is therefore
stable. The care organisation gets in contact with
the hospital staff and Fred is reassured.
Fred sees his primary care doctor, who
reviews the care plan and adds some
rehabilitation, which gets transmitted to
the care plan. Resources are automatically
booked and the budget is checked to
ensure that everything is covered. The primary care doctor organises the transport
and appointments for Fred, who recovers
quickly. He messages his friends on social
media and, using his new wheelchair, he is able
to meet them at the local park.
Fred and his friends continue to meet, interact and exercise within
their limitations, but secure in the knowledge that they are cared for.
AGED LIVING WITH TECHNOLOGYAGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
SMART HOMES AND SENSORS
Smart homes and intelligent housing, along sound (for detecting the sounds of daily living),
with the management of the physical environ- pressure (for detecting sit and standing trans-
ment through digital technologies for ambient fers), floor vibration, doppler radar and contact
assisted living, offer many solutions that sensors are used for such purposes. The data
improve quality of life, facility management, can be extracted and analysed using machine
and care provider productivity. Particularly when learning to recognise events and deviations and
implemented through converged platforms, potentially predict events, such as falls or med-
these can reduce the burden on the elderly by ical episodes.
simplifying, automating or allowing single-point
remote monitoring of a range of different tech- However, until now, research has provided few
nologies: bio-medical devices, security devices, satisfactory solutions in all areas of ambient
device alarms, cleaning and kitchen devices (for assisted living for safety, health, and comfort.
example, when a person leaves the gas or water Most models are deterministic and based upon
run too long), resident movement sensors, and
lights and utility devices. This can help address UNTIL NOW, RESEARCH HAS PROVIDED 22
the needs of people suffering from cognitive FEW SATISFACTORY SOLUTIONS IN ALL
decline or Alzheimer’s disease (Chan et al., AREAS OF AMBIENT ASSISTED LIVING
2009).
rigidly repeated patterns. As Uddin et al. say:
Sensors can be wearable or ambient. Wearable “there is a lack of suitable outcomes to validate
sensors can become uncomfortable and the the installation, management and delivery of
elderly may reject them or forget to use them. technological solutions to meet specific needs”
Ambient sensors do not have this drawback, (2018, p 21).
and if they provide adequate data and function,
they can be readily accepted. Ambient sensors One literature review of research on smart
are embedded into daily living environments homes for health monitoring of the elderly
(Uddin et al., 2018). Ambient sensor systems found low technology readiness and a paucity
currently focus on activity monitoring with a of research. They also found little evidence that
view to assessing immediate threats or events smart homes or health monitoring can predict
rather than long-term risks and care (Al-Shaqi disability or prevent falls. Few if any studies use
et al., 2016). However, they may represent a a technology adoption model, and economic
greater investment while being less flexible and analyses are rare (Liu et al., 2016).
harder to upgrade as technology advances.
Furthermore, the factors inhibiting adoption by
The events that sensors aim to address are the elderly – such as privacy, cost and intrusion
the activities of daily living, falls, localisation, – are not well understood. The commercial and
health status monitoring, sleeping patterns and adoption case for smart home technology is
gait. Ambient sensors such as passive infrared therefore far from complete.
motion (PIR), video (the most common one),AGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
ROBOTS
Robots may play a significant role in assisting responding to emergencies was concerned.
the elderly to age in place. Robots can be clas- Indeed, the elderly were positive about any
sified as service robots – for example, robots useful capability that gave them the ability to
that accomplish tasks that are challenging for determine their own lives, irrespective of their
the frail – or companion robots that provide decline in cognitive and physical function. But in
entertainment and communication and help a small multi-perspective evaluation of service
overcome isolation (Zafrani & Nimrod, 2019). It robots, Bedaf et al. found that while older people
is hoped that social robots can promote mental seemed keener to use them than their caregivers
health and medication compliance and reduce or relatives, robot functionality was too limited
anxiety and agitation, but research results are (2017). The levels of flexibility, personalisation
not yet clear on this point (Pu et al., 2019). and responsiveness demanded were similar to
those demanded of a human carer, suggesting
In a study to assess readiness to use robots, Park further progress in robot technology is required
et al. (2019) found that the elderly responded (Bedaf et al., 2017).
positively to robots as far as detecting and 23
TECHNOLOGY PUSH
There are several pitfalls regarding the appli- independent longevity shows that lifelong local
cation of technology to aging. The first pitfall friends and social engagement, family support,
concerns the general consequences of a push continuous incidental movement and a healthy
approach: these arise when technology providers diet are key elements of resilient, healthy and
develop “solutions” for a perceived market with independent aging. Interventions to encourage
little depth analysis for demand, suitability, con- this require stronger, often low-tech solutions
cerns and barriers for users, stakeholders, and and more general social policy around soci-
institutional frameworks, such as insurance or
government policy. For example, online grocery THE PRESENCE OF HEALTH
shopping could easily be seen as a functional AND SAFETY MONITORING CAN
solution for the elderly, particularly in the time of BRING GREAT COMFORT
COVID-19, but the reality is that for many, a walk
to the shops to buy one item can be an import- etal infrastructure, community engagement,
ant part of their daily exercise routine as well as and architecture, urban planning, clinical care
offering a change of scene and social interaction and healthcare facility management. All these
with others, such as a grocer, their neighbours stakeholders should be educated to familiarise
or others in the shop. them with a synergistic and holistic approach
to understanding and supporting aging at the
The second is that, in many cases, technology operational level (Illario et al., 2016).
may not even be the right solution: in fact, tech-
nology may be a tool that enables an undesirable This is not to say that technology is unimportant,
state to continue. Much research into healthy, quite the contrary. The presence of health andA report by the US National Research Council into adaptive aging argued that several
conditions must be met for technology to be adopted (Pew & Van Hemel, 2004):
Interest in efficiency and productivity of the care process
The safety of devices and their functions must be obvious, and things that reduce
safety – such as proliferation of distracting information – must be avoided.
Culture and language variations affect demand and uptake.
The elderly are sensitive to stigmas associated with aging, so care must be taken to
avoid self-stereotyping and pejorative images of products that make the recipient
or user seem infirm or deficient.
Usability barriers are higher than among the general population, so extreme design
for usability is required. Customisation to a specific, personal set of needs must be
easily achievable.
Privacy must be assured, as much of the information is highly personal, and
people fear misuse or access by unauthorised people.
One size does not fit all, so design criteria must be rigorously researched. There are
significant differences between seniors that must be catered for and products must
be easily configurable.
Trust must be built in technology through reliability, ease of use, simplicity and so
on.
PRE-CONDITIONS FOR ADOPTIONAGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER safety monitoring can bring great comfort and technological products should always be viewed assurance to the elderly and their families while with the primary objective in mind: how can the providing economies of scale that make it pos- elderly be supported in leading independent, sible for care providers to deliver it at affordable healthy lives for as long as possible. And this, prices (Chrysikou et al., 2016). And as younger by necessity, must include frameworks and pol- generations age, computer-mediated socialising icies that address people, regulation, physical or personal robots may become a natural part spaces, relationships and participants’ beliefs of the household landscape. But individual and attitudes. ATTITUDES TO TECHNOLOGY USE Pre-adoption, the most important benefit of independence (Tsertsidis et al., 2019). Concerns technology for aging perceived by the elderly is persist about information accuracy, lack of an increase in safety and usefulness, followed control over data and the recipient, anxiety by increased independence and a reduction in about becoming dependent, lack of adaptability, 25 their sense of being a burden on family caregiv- easily forgetting functions, stigmatisation and ers. Other factors include the desire to age in insufficient training. But older people are a very place, cultural background, existing familiarity heterogeneous group: just because people are with technology and the type of housing (Peek old does not mean that they share any particular et al., 2014). After actual use of the technologies, beliefs about technology. Attitudes, which are at users may feel increased communication and the heart of their willingness to use technolo- companionship, safety and security, personal gies, are embedded in their personal, cultural, capability to perform the activities of daily living economic, social and physical context (Peek et (ADL), trust in the reliability of the systems, al., 2016). awareness of their own health condition and PARTICIPATORY DESIGN Technology producers build values and assump- alarms, interventions and a feeling of intrusion tions about the elderly into their products that and external control. For example, the fear of can disrupt and impinge upon the autonomy of creating unnecessary and invasive callouts will elderly individuals. In particular, it can problema- cause older people to limit their own behaviours tise older adults and construct them as being for fear of triggering an alarm or placing too homogeneous and passive recipients of care, as much pressure on family as the initial responder. well as introducing changes to power relations This can cause recipients of passive monitoring that alter behaviour. to abandon such systems (Berridge, 2017). For the individuals being monitored, their typi- Furthermore, the elderly are not passive recip- cal behaviours become norms, and changes to ients of such monitoring: they adapt their these behaviours become deviations that trigger behaviour to refuse it, to work around it and
AGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER avoid alarms, or indeed to cause alarms in determination of the purpose of passive moni- order to obtain some human contact (Berridge, toring is not neutral and leads inevitably to poor 2017). The marginalisation of older adults in outcomes. the design, development and especially in the THE TECHNOLOGICAL CONTEXT As with many technology and medical prod- buildings and technologies and their different ucts and services, there are a number of less life cycles are important: a smartphone will be subjective considerations influencing adoption. upgraded perhaps regularly and easily, whereas For example, is the technology interoperable a home with built-in features is a long-term with other devices, manufacturers, or systems, investment and difficult to change. For many, is it approved by regulators, what is the level approval or underwriting by a health insurance of support or warranty and how invasive is provider will be critical in accepting a technol- maintenance? As new products and protocols ogy. The technological, institutional and eco- 26 are introduced or upgraded, will the elderly find nomic reality into which assistive technologies themselves in an endless cycle of technology are to be implemented must be understood and glitches, feature changes, software upgrades navigated in order to achieve movement into the and obsolescence? The physical instantiation of market, uptake and productive use.
CONCLUSION
Gaps in knowledge and proposal
for research approachesAGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
In summary, the health and care sectors are A key finding of this white paper is the need for a
increasingly going digital as new technologies strategic multi-disciplinary approach to research
emerge. Unfortunately, these digital solutions and design of solutions for aging. In the fields of
are not proven to be ready to use – often they do aged care, healthcare, digital technology, district
not meet either the natural expectations of the planning, neighbourhood development and
elderly or the wider living environment in which housing construction, there are different prob-
they find themselves. The elderly must adapt to lems to solve, decoupled lifecycles and varying
complex and inflexible technical systems, which institutional and regulatory contexts, but what
are often not unified, consistent, or seamless. these fields share is the objective of creating
This causes various problems – people may be environments that support the elderly in living
unable to adapt their living conditions to utilise healthy, socially integrated and independent lives
these digital solutions and consequently have for as long as possible. The DUCAH Learning
to move to a nursing home or they may misuse Lab initiative provides an environment in which
the technology or seek to work around it so as such collaborative forums can be facilitated and
not to be disruptive or be a burden. Second, inform the research and solution design needs
most research settings in this field are similarly of all stakeholders.
dysfunctional – they are highly artificial and built 28
around the technologies to be researched rather The DUCAH approach addresses three different
than the desired outcome. They thus resemble levels at which the research and practice actors
technology showrooms rather than the living work together in idea teams: 1. specification
environment in which they will be used. and matching, 2. (data) integration and 3.
regulation and policy. First, there is the level
Both issues need to be addressed. HIIG and of matching, in which existing solutions from
ECDF’s Digital Urban Center for Aging and technology providers are brought together with
Health (DUCAH) and its Learning Labs in Berlin the care facilities or housing companies. Here,
and all over Germany, is a research environment a human-centred, participation-oriented testing
that explores a fundamentally different kind of of existing digitally supported innovations takes
solution, namely systems that adapt to people place in the neighbourhood, care home and
and their lives. It involves older people with a hospital. Second, there is the data integration
range of characteristics in participatory design level. Here, the diverse stakeholders of the ideas
and research across the full product and service team dedicate themselves to the prototyping
of an interoperable digital platform for neigh-
DUCAH OFFERS A RESEARCH bourhoods, taking into account the integration
ENVIRONMENT TO EXPLORE SYSTEMS of different applications and user groups. Third,
THAT ADAPT TO PEOPLE AND THEIR LIVES there is the regulation and policy level. On this
level, urgently needed financing concepts are
process. It engages researchers, care provid- considered. Reinvestment of profits in the health
ers, entrepreneurs and other stakeholders in sector, models for social return instruments,
developing and testing digital health and care and new ideas for refinancing innovations and
solutions that help preserve the existing social start-ups are the focus of research here.
environment for all generations, thus offering
an example for how to implement multi-sided Most research until now into technology for
platforms and research in human-centred digital aging has employed product evaluation, surveys
field studies. and interviews, and observation of product useThe Learning Lab explores and innovates systems that adapt to people and their lives. The
people who live and work here are involved in participatory design and research across the
full product and service process. Researchers, care providers, entrepreneurs and other
stakeholders are engaged in developing and testing digital health and care solutions that
help preserve the existing social environment for all generations. The findings are
transferred to the health sector and policy.
DUCAH LEARNING LABAGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER under laboratory conditions. Some use has been not on the general class of technologies required made of technology acceptance models, but to support aging in place. While individual stud- such models fail to account for the bio-physical ies of system usability, efficacy and adoption are changes of aging as well as psychological and important, it is essential to observe and evaluate contextual factors. Further, technology accep- such systems in lived environments: tance studies focus on specific technologies and – To understand what resources are needed in a location to meet the requirements of a healthy life as older people decline in health and functional capacity – To ensure that products and services consider ethical boundaries and are not pushed onto vulnerable subjects (Flick et al., 2020) – To observe and understand how people actually use (or don’t use) products and how they feel about them and to grasp what their concerns are in reality about privacy, stigma or being a burden – To understand the interplay between different technologies and affordances 30 – To understand the ability of the elderly, in different stages of their lives, to cope with technologies – To understand the relative role of the technology within the whole context of the lived environment, including the neighbourhood, and technology interoperability, evolution and support – To provide an ecological context for trialling and observing how technology affects different stakehold- ers in the same context (the elderly, the spouse, relatives, caregivers, other service providers) – To assess actual efficiency and productivity gains from the use of technology The Learning Lab project will build upon examining Humanoid and Social Robots and HIIG’s and ECDF´s considerable experience the ethical considerations, regulatory require- in interdisciplinary research and a variety of ments and legal repercussions that their use in research projects that focus on creating socially care raises; it is also developing models for Data acceptable solutions for the digital society. HIIG Governance that encourage data sharing and and ECDF will transfer and build upon results re-use to foster innovation and increase eco- from previous projects such as: The Futures nomic and social welfare and facilitate Digital of Telemedicine: Knowledge, Policy, Regulation Innovation in German SMEs. and Privacy by Design in Smart Cities. HIIG is
AGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
PROPOSALS FOR RESEARCH
The scope of aging research is enormous and to introduce and research any areas that are
covers a wide range of disciplines. First, as a amenable to this approach. The first projects will
foundational principle, HIIG and ECDF will build upon previous knowledge accumulated in
research the lived experience of the elderly and research projects in the health and technology
their interactions with technologies of all kinds. sectors. Some initial project concepts and
The means for doing this is the Learning Lab research questions within the DUCAH idea
concept. Second, HIIG and ECDF will be able teams are as follows:
– Which data models in home care and aging at home are needed to ensure that life in old age is
dignified and self-determined for as long as possible? What are fair and reasonable approaches to
sharing the benefits of captured data between the elderly person being monitored and the companies
gathering and analysing that data?
– What are the best practice smart home designs specifically for the elderly?
31
– How should multi-sided platforms be designed so that they offer sufficiently economically attractive
incentives for participating companies and also beneficial, simple, and intuitive use for the elderly,
with fair treatment of the data provided?
– How and in what form is work changing in the context of digitally supported care and age-appropriate
furnishing of residential units?
– What innovative business models can be created in the interplay of care facilities, real estate and
neighbourhood developers, technology companies, financial and insurance service providers, busi-
ness advisors and other industrial companies with the focus on digital urban health and aging?
Others include:
– Social investing: how can community resources, perhaps a social impact bond or community hack-
athons with local startups for example, be mobilised to invest in applications that may eventually
generate a return?
– Electronic health records: what are the benefits, costs, challenges, and risks of incorporating data
from aging services technologies into master electronic health records?
– Data privacy and ownership: as large amounts of sensitive, personal data are captured through mon-
itors and sensors, information management, data lineage and governance over the data will become
especially important (von Grafenstein et al., 2019). Further, the voluminous, continuous data is a
perfect subject for big data analytics and machine learning, which can use it to predict events such as
falls or seizures or even incipient chronic disease. But who owns this data, and who has the rights to
use it to gain commercial advantage (Zuboff, 2019)?AGING, INDEPENDENT LIVING AND TECHNOLOGY A WHITEPAPER
RESEARCH APPROACHES AND THE LEARNING LAB
Despite a wide range of emerging and current totalising, imposed and coercive (Bächle, 2020).
technologies, there are significant challenges Understanding needs and individual creativity in
for those wishing to implement technologies customising systems is essential to the ethical
for aging, including an uneven evidence base, use of telecare, and this customisation process
economic barriers, and educational and ergo- should be respected (Bächle, 2020). Indeed,
nomic issues that adversely affect many older as the final report into ethical frameworks for
adults. For example, great care must be taken healthcare technologies for older people at
to ensure that telecare systems avoid becoming home found:
“… telecare does not offer a technological fix’ to replace either traditional healthcare ser-
vices or informal care networks: it is not an easy solution to demographic ageing, ‘care
crises’, personnel crises, or budget crises in ageing societies. Telecare does not perform
care on its own. Respondents expressed grave concerns that telecare technologies might
be used to replace face-to-face or hands-on care in order to cut costs.” (Mort, 2011).
32
Peine and Neven (2019) contend that an inter- results. These results will in turn shape the tech-
ventionist logic in which aging is a target for nologies and the environments to achieve the
technological interventions has exacerbated ultimate goal – aging in place for the elderly.
the digital divide. They support an innovation
approach that utilises collaborative design, con- Above all, research must focus on the ultimate
siders the socio-material practices of older peo- goal: aging in place. Research into individual
ple and other stakeholders, and includes policy devices from technology companies is limited in
discourse as an element of design. Older people its usefulness. A better approach is to identify
must not be seen as a homogeneous group of
actors simply because they are the same age: RESEARCH MUST FOCUS ON THE
they will (not) use, modify, and produce technol- ULTIMATE GOAL: AGING IN PLACE
ogies in varied ways for many different, possibly
contradictory reasons. This is supported by packages of technologies that enhance a func-
Merkel and Kucharski (2019), who argue that it tional area, such as health or mobility, so that a
is important to include older users in all stages set of effective and affordable technologies can
of the innovation and development process. be introduced to improve aging in place for the
diverse elderly population. This will also require
How the elderly perceive and use technology to multidisciplinary teams of technologists, geron-
enable living at home is driven by their personal, tologists, clinicians, and public health research-
social, cognitive, and physical contexts – and ers and collaborations with policy makers, com-
these vary widely and change over time. Careful munity administrators, technology developers
consideration is needed to determine how to and the other participating stakeholders.
design, implement and adapt technologies to
support living in place. Evaluation must capture The concept of Living Labs has gained cur-
the interplay of these elements over time in real- rency as a way of testing applications within
life environments in order to provide meaningful an existing social environment (Keyson et al.,You can also read
